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  • imageThe goal of pharmacotherapy is seizure freedom with minimal adverse effects. Between 60% and 80% of patients can achieve this.

  • imageAccurate classification and diagnosis of seizure type/epilepsy syndrome, including where seizures begin, is critical to selection of appropriate pharmacotherapy.

  • imageBesides seizure type, antiseizure medication (ASM) selection depends on patient characteristics such as age, sex, ethnicity, susceptibility to adverse medication effects, comorbid conditions, ability to adhere with the prescribed regimen, presence or absence of insurance coverage, and need for therapeutic levels to be reached quickly.

  • imagePharmacotherapy for epilepsy is highly individualized and requires dose titration to optimize therapy (maximal seizure control with minimal or no adverse medication effects).

  • imageIf the therapeutic goal is not achieved with monotherapy, a second ASM, preferably with a different mechanism of action, can be added. The patient’s ASM can also be switched to an alternative single agent.

  • imagePatients who do not respond to pharmacotherapy should be referred to a comprehensive epilepsy center to determine if nonpharmacologic treatments such as surgery are potential options.

  • imageIn general, first-generation ASMs are very efficacious but have complex pharmacokinetics, multiple medication interactions, and an increased incidence of adverse effects, which make them more complicated to manage than either the second- or third-generation ASMs.

  • imageSecond-generation ASMs have unique mechanisms of action and are as efficacious as first- and third-generation ASMs with better tolerability. They are generally considered first-line epilepsy pharmacotherapy.

  • imageThird-generation ASMs should be reserved for failure of other agents due to cost and limited long-term experience.

  • image20% to 35% of patients will have unsatisfactory control with ASMs and will be considered to be treatment-resistant.


Patient Care Process for Epilepsy



  • Patient-specific demographics (eg, age, race, sex, pregnancy status, and desire for pregnancy)

  • A detailed description of seizure semiology from the patient and a witness of the seizure, including the following:

    • Degree of mental status impairment during the event

    • Presence of ictal motor, sensory, autonomic, or other features at onset of the seizure (Fig. 75-1)

    • Tongue biting, cheek biting, and bladder or bowel incontinence during the seizures

    • Seizure time course and any postictal phenomena (eg, fatigue, headaches, confusion, and psychosis)

  • Frequency of seizure events and any precipitating factors

  • Information on comorbid medical psychiatric, and neurodevelopmental conditions including depression, anxiety, and learning and development conditions

  • Family history of epilepsy, risk factors for epilepsy including injury at birth, history of meningitis or encephalitis, history of traumatic brain injury

  • Current and past medications including antiseizure medications (ASMs)

  • Duration of past ASM therapy and response to each ASM (eg, decrease or increase in seizure frequency and adverse medication reactions experienced)

  • Allergies to medications including ASMs

  • Laboratory values for electrolytes and glucose to rule out provoked seizures, baseline test for renal function, liver function, and complete blood count (CBC)

  • Magnetic resonance imaging (MRI) of brain without contrast

  • Electroencephalogram (EEG)


  • Seizure, epilepsy, and epilepsy syndrome classification (Figs. 73-1 and 73-2)


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